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Habarth-Morales TE, Davis HD, Duca A, Salinero LK, Chandragiri S, Rios-Diaz AJ, Broach RB, Caterson EJ, Swanson JW. Factors associated with late surgical correction of craniosynostosis: A decade-long review of the United States nationwide readmission database. J Craniomaxillofac Surg 2024; 52:585-590. [PMID: 38448339 DOI: 10.1016/j.jcms.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 02/11/2024] [Indexed: 03/08/2024] Open
Abstract
Late-repair craniosynostosis (LRC), defined as craniosynostosis surgery beyond 1 year of age, is often associated with increased complexity and potential complications. Our study analyzed data from the 2010-2019 Nationwide Readmissions Database to investigate patient factors related to LRC. Of 10 830 craniosynostosis repair cases, 17% were LRC. These patients were predominantly from lower-income families and had more comorbidities, indicating that socioeconomic status could be a significant contributor. LRC patients were typically treated at teaching hospitals and privately owned investment institutions. Our risk-adjusted analysis revealed that LRC patients were more likely to belong to the lowest-income quartile, receive treatment at privately owned investment hospitals, and use self-payment methods. Despite these challenges, the hospital stay duration did not significantly differ between the two groups. Interestingly, LRC patients faced a higher predicted mean total cost compared with those who had surgery before turning 1. This difference in cost did not translate to a longer length of stay, further emphasizing the complexity of managing LRC. These findings highlight the urgent need for earlier intervention in craniosynostosis cases, particularly in lower-income communities. The medical community must strive to improve early diagnosis and treatment strategies in order to mitigate the socioeconomic and health disparities observed in LRC patients.
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Affiliation(s)
- Theodore E Habarth-Morales
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA; Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Harrison D Davis
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA; Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Aviana Duca
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lauren K Salinero
- Division of Plastic, Reconstructive, and Oral Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Shreyas Chandragiri
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA; Division of Plastic Surgery, Department of Surgery, Nemours Children's Health, Wilmington, DE, USA
| | - Arturo J Rios-Diaz
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Edward J Caterson
- Division of Plastic Surgery, Department of Surgery, Nemours Children's Health, Wilmington, DE, USA
| | - Jordan W Swanson
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA; Division of Plastic, Reconstructive, and Oral Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Habarth-Morales TE, Rios-Diaz AJ, Isch E, Qi L, Ni R, Caterson EJ. Increased Incidence of Suspected Smoke Inhalation During the Coronavirus Disease 2019 Pandemic: A National Database Study. J Burn Care Res 2023; 44:945-948. [PMID: 36260537 PMCID: PMC9620764 DOI: 10.1093/jbcr/irac155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Indexed: 11/13/2022]
Abstract
The COVID-19 pandemic has forced many Americans to adapt their daily routines. In 2020, there was a significant increase in house fires according to the National Fire Prevention Association (NFPA). The objective of this study was to characterize the changes in suspected smoke inhalations (SSIs) during the first year of the pandemic in the National Emergency Medical Services Information System (NEMSIS). The NEMSIS database was queried for all EMS transports captured between 2017 and 2020. Differences in the incidences of SSIs and fire dispatches in 2020 were estimated using Poisson regression models. There was a 13.4% increase in the incidence of fire dispatches and a 15% increase in SSIs transported in 2020 compared to the previous 3 years. The incidence rate ratio of both fire dispatches (1.271; 95% CI: 1.254-1.288; P < .001) and SSI (1.152; 95% CI: 1.070-1.241; P < .001) was significantly elevated in 2020. The increases in fire dispatches and SSIs observed in the NEMSIS database are in concordance with other literature indicating the increase in fire incidence and morbidity observed during the pandemic. These results should inform fire prevention outreach efforts and resource allocation in burn centers in the event of future pandemic.
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Affiliation(s)
- Theodore E Habarth-Morales
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States of America
- Division of Plastic Surgery, Department of Surgery, Nemours Children’s Health, Wilmington, DE, United States of America
| | - Arturo J Rios-Diaz
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Emily Isch
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Lucy Qi
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Rose Ni
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Edward J Caterson
- Division of Plastic Surgery, Department of Surgery, Nemours Children’s Health, Wilmington, DE, United States of America
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Cunning JR, Mookerjee VG, Alper DP, Rios-Diaz AJ, Bauder AR, Kimia R, Broach RB, Barrette LX, Fischer JP, Butler PD. How Does Reduction Mammaplasty Surgical Technique Impact Clinical, Aesthetic, and Patient-Reported Outcomes?: A Comparison of the Superomedial and Inferior Pedicle Techniques. Ann Plast Surg 2023; 91:28-35. [PMID: 37450858 DOI: 10.1097/sap.0000000000003610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND A comprehensive comparison of surgical, aesthetic, and quality of life outcomes by reduction mammaplasty technique does not exist. We sought to ascertain the effect of technique on clinical, aesthetic, and patient-reported outcomes. METHODS Patients with symptomatic macromastia undergoing a superomedial or inferior pedicle reduction mammoplasty by a single surgeon were identified. BREAST-Q surveys were administered. Postoperative breast aesthetics were assessed in 50 matched-patients. Patient characteristics, complications, quality of life, and aesthetic scores were analyzed. RESULTS Overall, 101 patients underwent reductions; 60.3% had a superomedial pedicle. Superomedial pedicle patients were more likely to have grade 3 ptosis (P < 0.01) and had significantly shorter procedure time (P < 0.01). Only the inferior pedicle technique resulted in wound dehiscence (P = 0.03) and reoperations from complications (P < 0.01). Those who underwent an inferior pedicle reduction were 4.3 times more likely to experience a postoperative complication (P = 0.03). No differences in quality of life existed between cohorts (P > 0.05). Superomedial pedicle patients received significantly better scarring scores (P = 0.03). CONCLUSIONS The superomedial pedicle reduction mammoplasty technique provides clinical and aesthetic benefits compared with the inferior pedicle technique.
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Affiliation(s)
| | - Vikram G Mookerjee
- Division of Plastic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - David P Alper
- Division of Plastic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Arturo J Rios-Diaz
- From the Division of Plastic Surgery, University of Pennsylvania, Philadelphia
| | - Andrew R Bauder
- From the Division of Plastic Surgery, University of Pennsylvania, Philadelphia
| | | | - Robyn B Broach
- From the Division of Plastic Surgery, University of Pennsylvania, Philadelphia
| | | | - John P Fischer
- From the Division of Plastic Surgery, University of Pennsylvania, Philadelphia
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Rios-Diaz AJ, Morris MP, Christopher AN, Patel V, Broach RB, Heniford BT, Hsu JY, Fischer JP. National epidemiologic trends (2008-2018) in the United States for the incidence and expenditures associated with incisional hernia in relation to abdominal surgery. Hernia 2022; 26:1355-1368. [PMID: 36006563 DOI: 10.1007/s10029-022-02644-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/04/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE It is unknown whether the trend of rising incisional hernia (IH) repair (IHR) incidence and costs until 2011 currently persists. We aimed to evaluate how the IHR procedure incidence, cost and patient risk-profile have changed over the last decade relative to all abdominal surgeries (AS). METHODS Repeated cross-sectional analysis of 38,512,737 patients undergoing inpatient 4AS including IHR within the 2008-2018 National Inpatient Sample. Yearly incidence (procedures/1,000,000 people [PMP]), hospital costs, surgical and patient characteristics were compared between IHR and AS using generalized linear and multinomial regression. RESULTS Between 2008-2018, 3.1% of AS were IHR (1,200,568/38,512,737). There was a steeper decrease in the incidence of AS (356.5 PMP/year) compared to IHR procedures (12.0 PMP/year) which resulted in the IHR burden relative to AS (2008-2018: 12,576.3 to 9,113.4 PMP; trend difference P < 0.01). National costs averaged $47.9 and 1.7 billion/year for AS and IHR, respectively. From 2008-2018, procedure costs increased significantly for AS (68.2%) and IHR (74.6%; trends P < 0.01). Open IHR downtrended (42.2%), whereas laparoscopic (511.1%) and robotic (19,301%) uptrended significantly (trends P < 0.01). For both AS and IHR, the proportion of older (65-85y), Black and Hispanic, publicly-insured, and low-income patients, with higher comorbidity burden, undergoing elective procedures at small- and medium-sized hospitals uptrended significantly (all P < 0.01). CONCLUSION IH persists as a healthcare burden as demonstrated by the increased proportion of IHR relative to all AS, disproportionate presence of high-risk patients that undergo these procedures, and increased costs. Targeted efforts for IH prevention have the potential of decreasing $17 M/year in costs for every 1% reduction.
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Affiliation(s)
- A J Rios-Diaz
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - M P Morris
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA
| | - A N Christopher
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - V Patel
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA
| | - R B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA
| | - B T Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - J Y Hsu
- Center for Clinical Epidemiology and Biostatistics (CCEB), University of Pennsylvania, Philadelphia, PA, USA
| | - J P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, 51 North 39th Street, Wright Saunders Building, Philadelphia, PA, 19104, USA.
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Rios-Diaz AJ, Cunning JR, Talwar AA, Christopher A, Broach RB, Hsu JY, Morris JB, Fischer JP. Reoperation Through a Prosthetic-Reinforced Abdominal Wall and Its Association With Postoperative Outcomes and Longitudinal Health Care Utilization. JAMA Surg 2022; 157:908-916. [PMID: 35921101 PMCID: PMC9350843 DOI: 10.1001/jamasurg.2022.3320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Prosthetic reinforcement of critically sized incisional hernias is necessary to decrease hernia recurrence, but long-term prosthetic-mesh footprint may increase complication risk during subsequent abdominal operations. Objective To investigate the association of prior incisional hernia repair with mesh (IHRWM) with postoperative outcomes and health care utilization after common abdominal operations. Design, Setting, and Participants This was a population-based, retrospective cohort study of patients undergoing inpatient abdominal surgical procedures during the period of January 2009 to December 2016, with at least 1 year of follow-up within 5 geographically diverse statewide inpatient/ambulatory databases (Florida, Iowa, Nebraska, New York, Utah). History of an abdominal operation was ascertained within the 3-year period preceding the index operation. Patients admitted to the hospital with a history of an abdominal operation (ie, bariatric, cholecystectomy, small- or large-bowel resection, prostatectomy, gynecologic) were identified using the International Classification of Diseases, Ninth Revision and Tenth Revision, Clinical Modification procedure codes. Patients with prior IHRWM were propensity score matched (1:1) to controls both with and without a history of an abdominal surgical procedure based on clinical and operative characteristics. Data analysis was conducted from March 1 to November 27, 2021. Main Outcomes and Measures The primary outcome was a composite of adverse postoperative outcomes (surgical and nonsurgical). Secondary outcomes included health care utilization determined by length of hospital stay, hospital charges, and 1-year readmissions. Logistic and Cox regression determined the association of prior IHRWM with the outcomes of interest. Additional subanalyses matched and compared patients with prior IHR without mesh (IHRWOM) to those with a history of an abdominal operation. Results Of the 914 105 patients undergoing common abdominal surgical procedures (81 123 bariatric [8.9%], 284 450 small- or large-bowel resection [31.1%], 223 768 cholecystectomy [24.5%], 33 183 prostatectomy [3.6%], and 291 581 gynecologic [31.9%]), all 3517 patients (age group: 46-55 years, 1547 [44.0%]; 2396 majority sex [68.1%]) with prior IHRWM were matched to patients without a history of abdominal surgical procedures. After matching, prior IHRWM was associated with increased overall complications (odds ratio [OR], 1.43; 95% CI, 1.27-1.60), surgical complications (OR, 1.51; 95% CI, 1.34-1.70), length of hospital stay (mean increase of 1.03 days; 95% CI, 0.56-1.49 days; P < .001), index admission charges (predicted mean difference of $11 896.10; 95% CI, $6096.80-$17 695.40; P < .001), and 1-year unplanned readmissions (hazard ratio, 1.14; 95% CI, 1.05-1.25; P = .002). This trend persisted even when comparing matched patients with prior IHRWM to patients with a history of abdominal surgical procedures, and the treatment outcome disappeared when comparing patients with prior IHRWOM to those without a previous abdominal operation. Conclusions and Relevance Reoperation through a previously prosthetic-reinforced abdominal wall was associated with increased surgical complications and health care utilization. This risk appeared to be independent of a history of abdominal surgical procedures and was magnified by the presence of a prosthetic-mesh footprint in the abdominal wall.
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Affiliation(s)
- Arturo J Rios-Diaz
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia.,Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jessica R Cunning
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Ankoor A Talwar
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Adrienne Christopher
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia.,Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Jesse Y Hsu
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia
| | - Jon B Morris
- Division of Gastrointestinal Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
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Habarth-Morales TE, Rios-Diaz AJ, Caterson EJ. Pandemic Puppies: Man's Best Friend or Public Health Problem? A Multidatabase Study. J Surg Res 2022; 276:203-207. [PMID: 35378364 PMCID: PMC9576631 DOI: 10.1016/j.jss.2022.02.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 02/15/2022] [Accepted: 02/17/2022] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The public health implications of the COVID-19 pandemic reach beyond those of the disease itself. Various centers have anecdotally reported increases in the incidence of dog bite injuries which predominate in pediatric populations. The reasons for this increase are likely multifactorial and include an increase in canine adoptions, remote learning, and psychosocial stressors induced by lockdowns. We hypothesized that there was a significant increase in the proportion of dog bite injuries at our institution and within a nationally representative cohort. METHODS We queried our electronic health record and the National Electronic Injury Surveillance System (NEISS) for all records pertaining to dog bites between 2015 and 2020, and the annual incidence was calculated. Poisson regression was then used to estimate whether there was a significant difference in the adjusted risk ratio for each year. RESULTS The institutional and national cohorts revealed relative increases in the incidence of dog bite injury of 243 and 147.9 per 100,000 over the study period, respectively. Both cohorts observed significant increases of 44% and 25% in the annual incidence relative to 2019, respectively. Poisson regression revealed a significantly elevated adjusted relative risk in the institutional cohort for 2020 (2.664, CI: 2.076-3.419, P < 0.001). The national cohort also revealed an increase (1.129, CI: 1.091-1.169, P < 0.001). CONCLUSIONS A nationwide increase in the incidence of dog bite injuries among children was observed during COVID-19 in 2020. These findings suggest that dog bites remain a public health problem that must be addressed by public health agencies.
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Affiliation(s)
- Theodore E Habarth-Morales
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania; Division of Plastic Surgery, Department of Surgery, Nemours Children's Health, Wilmington, Delaware
| | - Arturo J Rios-Diaz
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Edward J Caterson
- Division of Plastic Surgery, Department of Surgery, Nemours Children's Health, Wilmington, Delaware.
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Habarth-Morales TE, Rios-Diaz AJ, Gadomski SP, Stanley T, Donnelly JP, Koenig GJ, Cohen MJ, Marks JA. Direct to OR resuscitation of abdominal trauma: An NTDB propensity matched outcomes study. J Trauma Acute Care Surg 2022; 92:792-799. [PMID: 35045059 DOI: 10.1097/ta.0000000000003536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Direct to operating room resuscitation (DOR) is used by some trauma centers for severely injured trauma patients as an approach to minimize time to hemorrhage control. It is unknown whether this strategy results in favorable outcomes. We hypothesized that utilization of an emergency department operating room (EDOR) for resuscitation of patients with abdominal trauma at an urban Level I trauma center would be associated with decreased time to laparotomy and improved outcomes. METHODS We included patients 15 years or older with abdominal trauma who underwent emergent laparotomy within 120 minutes of arrival both at our institution and within a National Trauma Data Bank sample between 2007 to 2019 and 2013 to 2016, respectively. Our institutional sample was matched 1:1 to an American College of Surgeons National Trauma Databank sample using propensity score matching based on age, sex, mechanism of injury, and abdominal Abbreviated Injury Scale score. The primary outcome was time to laparotomy incision. Secondary outcomes included blood transfusion requirement, intensive care unit (ICU) length of stay (LOS), ventilator days, hospital LOS, and in-hospital mortality. RESULTS Two hundred forty patients were included (120 institutional, 120 national). Both samples were well balanced, and 83.3% sustained penetrating trauma. There were 84.2% young adults between the ages of 15 and 47, 91.7% were male, 47.5% Black/African American, with a median Injury Severity Score of 14 (interquartile range [IQR], 8-29), Glasgow Coma Scale score of 15 (IQR, 13-15), 71.7% had an systolic blood pressure of >90 mm Hg, and had a shock index of 0.9 (IQR, 0.7-1.1) which did not differ between groups (p > 0.05). Treatment in the EDOR was associated with decreased time to incision (25.5 minutes vs. 40 minutes; p ≤ 0.001), ICU LOS (1 vs. 3.1 days; p < 0.001), transfusion requirement within 24 hours (3 units vs. 5.8 units packed red blood cells; p = 0.025), hospital LOS (5 days vs. 8.5 days, p = 0.014), and ventilator days (1 day vs. 2 days; p ≤ 0.001). There were no significant differences in in-hospital mortality (22.5% vs. 15.0%; p = 0.14) or outcome-free days (4.9 days vs. 4.5 days, p = 0.55). CONCLUSION The use of an EDOR is associated with decreased time to hemorrhage control as evidenced by the decreased time to incision, blood transfusion requirement, ICU LOS, hospital LOS, and ventilator days. These findings support DOR for patients sustaining operative abdominal trauma. LEVEL OF EVIDENCE Therapeutic/Care Management, Level III.
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Affiliation(s)
- Theodore E Habarth-Morales
- From the Division of Trauma and Acute Care Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
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Rios-Diaz AJ, Lamm R, Metcalfe D, Devin CL, Pucci MJ, Palazzo F. National recurrence of pancreatitis and readmissions after biliary pancreatitis. Surg Endosc 2022; 36:7399-7408. [PMID: 35233658 DOI: 10.1007/s00464-022-09153-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 02/17/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND National and international guidelines support early cholecystectomy after mild gallstone pancreatitis but a recent nationwide study suggested these recommendations are not universally followed. Our study sought to quantify the national utilization of same hospitalization cholecystectomy versus non-operative management (NOM) and its association with pancreatitis recurrence, readmissions, and costs after mild gallstone pancreatitis (GP). METHODS Adult patients admitted with mild GP were identified from the Nationwide Readmission Database 2010-2015. Primary outcomes included the rate of cholecystectomy during the index admission as well as pancreatitis recurrence and readmission at 30 and 180 days (30d, 180d) comparing NOM to same hospitalization cholecystectomy. Mortality upon readmission, total length of stay (LOS), and total costs (combined index-readmission hospital costs) were also explored. Cox proportional hazards regression and generalized linear models controlled for patient/hospital confounders. RESULTS Among the 65,067 patients identified, 30% underwent cholecystectomy. The NOM cohort was older (58 vs. 50 years), had more comorbidities (Charlson index > 2, 23.5% vs. 11.5%), fewer female patients (56.7% vs. 67%) and less discharge-to-home (84.9% vs. 94.4%) (all p < 0.001). NOM was associated with increase in recurrence and unplanned readmissions at 30d [Hazard Ratio 3.53 (95% CI 2.92-4.27), 2.41 (2.11-2.74), respectively], and 180d [4.27 (3.65-4.98), 2.78 (2.54-3.04), respectively], as well as increased mortality during 180d readmission 1.88 (1.06-3.35). This approach was also associated with significant increase in LOS [predicted mean difference 2.79 days (95% CI 2.46-3.12)] and total costs [$2507.89 ($1714.4-$3301.4)]. CONCLUSIONS In the USA, most patients presenting with mild GP do not undergo same hospitalization cholecystectomy. This strategy results in higher recurrent pancreatitis, mortality during readmission, and an additional $4.85 M/year in hospital costs nationwide. These data support same hospitalization cholecystectomy as the gold standard for mild GP.
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Affiliation(s)
- Arturo J Rios-Diaz
- Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut Street, Philadelphia, PA, 19107, USA.
| | - Ryan Lamm
- Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut Street, Philadelphia, PA, 19107, USA
| | - David Metcalfe
- Rheumatology and Musculoskeletal Sciences (NDORMS), Nuffield Department of Orthopedics, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Courtney L Devin
- Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut Street, Philadelphia, PA, 19107, USA
| | - Michael J Pucci
- Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut Street, Philadelphia, PA, 19107, USA
| | - Francesco Palazzo
- Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut Street, Philadelphia, PA, 19107, USA
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Rios-Diaz AJ, Bevilacqua LA, Metcalfe D, Yeo CJ, Palazzo F. Are Traditional Metrics Sufficient to Capture the True Burden of Venous Thromboembolism after Elective Major Surgery? A Nationwide Analysis of 844,101 Patients and 30 Major Surgical Procedures. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Rios-Diaz AJ, Zalewski A, Bevilacqua LA, Metcalfe D, Costanzo C, Yeo CJ, Palazzo F. Primary Anastomosis with Diverting Loop Ileostomy vs Hartmann’s Procedure for Acute Diverticulitis: What Happens after Discharge? Results of a Nationwide Analysis. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Rios-Diaz AJ, Morris MP, Christopher AN, Patel V, Broach RB, Hsu JY, Serletti JM, Fischer JP. Trends in Incisional Hernia Repair and Abdominal Surgery: A Nationwide Analysis of Hospitalization and Hospital Cost. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Woo SH, Rios-Diaz AJ, Kubey AA, Cheney-Peters DR, Ackermann LL, Chalikonda DM, Venkataraman CM, Riley JM, Baram M. Development and Validation of a Web-Based Severe COVID-19 Risk Prediction Model. Am J Med Sci 2021; 362:355-362. [PMID: 34029558 PMCID: PMC8141270 DOI: 10.1016/j.amjms.2021.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 12/26/2020] [Accepted: 04/01/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) carries high morbidity and mortality globally. Identification of patients at risk for clinical deterioration upon presentation would aid in triaging, prognostication, and allocation of resources and experimental treatments. RESEARCH QUESTION Can we develop and validate a web-based risk prediction model for identification of patients who may develop severe COVID-19, defined as intensive care unit (ICU) admission, mechanical ventilation, and/or death? METHODS This retrospective cohort study reviewed 415 patients admitted to a large urban academic medical center and community hospitals. Covariates included demographic, clinical, and laboratory data. The independent association of predictors with severe COVID-19 was determined using multivariable logistic regression. A derivation cohort (n=311, 75%) was used to develop the prediction models. The models were tested by a validation cohort (n=104, 25%). RESULTS The median age was 66 years (Interquartile range [IQR] 54-77) and the majority were male (55%) and non-White (65.8%). The 14-day severe COVID-19 rate was 39.3%; 31.7% required ICU, 24.6% mechanical ventilation, and 21.2% died. Machine learning algorithms and clinical judgment were used to improve model performance and clinical utility, resulting in the selection of eight predictors: age, sex, dyspnea, diabetes mellitus, troponin, C-reactive protein, D-dimer, and aspartate aminotransferase. The discriminative ability was excellent for both the severe COVID-19 (training area under the curve [AUC]=0.82, validation AUC=0.82) and mortality (training AUC= 0.85, validation AUC=0.81) models. These models were incorporated into a mobile-friendly website. CONCLUSIONS This web-based risk prediction model can be used at the bedside for prediction of severe COVID-19 using data mostly available at the time of presentation.
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Affiliation(s)
- Sang H Woo
- Department of Medicine, Division of Hospital Medicine, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Arturo J Rios-Diaz
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alan A Kubey
- Department of Medicine, Division of Hospital Medicine, Thomas Jefferson University, Philadelphia, PA, USA; Department of Medicine, Division of Hospital Medicine, Mayo Clinic, Rochester, MN, USA
| | - Dianna R Cheney-Peters
- Department of Medicine, Division of Hospital Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lily L Ackermann
- Department of Medicine, Division of Hospital Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Divya M Chalikonda
- Department of Medicine, Division of Hospital Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Joshua M Riley
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael Baram
- Department of Medicine - Division of Pulmonary and Critical Care, Thomas Jefferson University. Philadelphia, PA, USA
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Rios-Diaz AJ, Cunning J, Hsu JY, Elfanagely O, Marks JA, Grenda TR, Reilly PM, Broach RB, Fischer JP. Incidence, Burden on the Health Care System, and Factors Associated With Incisional Hernia After Trauma Laparotomy. JAMA Surg 2021; 156:e213104. [PMID: 34259810 DOI: 10.1001/jamasurg.2021.3104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Importance The evidence provided supports routine and systematic capture of long-term outcomes after trauma, lengthening the follow-up for patients at risk for incisional hernia (IH) after trauma laparotomy (TL), counseling on the risk of IH during the postdischarge period, and consideration of preventive strategies before future abdominal operations to lessen IH prevalence as well as the patient and health care burden. Objective To determine burden of and factors associated with IH formation following TL at a population-based level across health care settings. Design, Setting, and Participants This population-based cohort study included adult patients who were admitted with traumatic injuries and underwent laparotomy with follow-up of 2 or more years. The study used 18 statewide databases containing data collected from January 2006 through December 2016 and corresponding to 6 states in diverse regions of the US. Longitudinal outcomes were identified within the Statewide Inpatient, Ambulatory, and Emergency Department Databases. Patients admitted with International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for traumatic injuries with 1 or more concurrent open abdominal operations were included. Data analysis was conducted from March 2020 through June 2020. Main Outcomes and Measures The primary outcome was IH after TL. Risk-adjusted Cox regression allowed identification of patient-level, operative, and postoperative factors associated with IH. Results Of 35 666 patients undergoing TL, 3127 (8.8%) developed IH (median [interquartile range] follow-up, 5.6 [3.4-8.6] years). Patients had a median age of 49 (interquartile range, 31-67) years, and most were male (21 014 [58.9%]), White (21 584 [60.5%]), and admitted for nonpenetrating trauma (28 909 [81.1%]). The 10-year IH rate and annual incidence were 11.1% (95% CI, 10.7%-11.5%) and 15.6 (95% CI, 15.1-16.2) cases per 1000 people, respectively. Within risk-adjusted analyses, reoperation (adjusted hazard ratio [aHR], 1.28 [95% CI, 1.2-1.37]) and subsequent abdominal surgeries (aHR, 1.71 [95% CI, 1.56-1.88]), as well as obesity (aHR, 1.88 [95% CI, 1.69-2.10]), intestinal procedures (aHR, 1.47 [95% CI, 1.36-1.59]), and public insurance (aHRs: Medicare, 1.38 [95% CI, 1.20-1.57]; Medicaid, 1.35 [95% CI, 1.21-1.51]) were among the variables most strongly associated with IH. Every additional reoperation at the index admission and subsequently resulted in a 28% (95% CI, 20%-37%) and 71% (95% CI, 56%-88%) increased risk for IH, respectively. Repair of IH represented an additional $36.1 million in aggregate costs (39.9%) relative to all index TL admissions. Conclusions and Relevance Incisional hernia after TL mirrors the epidemiology and patient profile characteristics seen in the elective setting. We identified patient-level, perioperative, and novel postoperative factors associated with IH, with obesity, intestinal procedures, and repeated disruption of the abdominal wall among the factors most strongly associated with this outcome. These data support preemptive strategies at the time of reoperation to lessen IH incidence. Longer follow-up may be considered after TL for patients at high risk for IH.
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Affiliation(s)
- Arturo J Rios-Diaz
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia.,Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jessica Cunning
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Jesse Y Hsu
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Pennsylvania
| | - Omar Elfanagely
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Joshua A Marks
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Tyler R Grenda
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Patrick M Reilly
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia
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14
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Rios-Diaz AJ, Woodward SG, Zheng R, McPartland C, Tholey R, Tatarian T, Palazzo F. Nationwide Subanalysis of Patient Profile for Same-Admission vs Post-Discharge Interval Cholecystectomy after Percutaneous Cholecystostomy Tube Placement: In Reply to Sakamoto and Lefor. J Am Coll Surg 2021; 233:157-158. [PMID: 33879371 DOI: 10.1016/j.jamcollsurg.2021.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 03/10/2021] [Indexed: 10/21/2022]
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15
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Meer E, Hughes BD, Martin CA, Rios-Diaz AJ, Patel V, Pugh CM, Berry C, Stain SC, Britt LD, Stein SL, Butler PD. Reassessing career pathways of surgical leaders: An examination of surgical leaders' early accomplishments. Am J Surg 2021; 222:933-936. [PMID: 33894978 DOI: 10.1016/j.amjsurg.2021.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/03/2021] [Accepted: 04/04/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The American College of Surgeon (ACS), American Surgical Association (ASA), Association of Women Surgeons (AWS), and Society of Black Academic Surgeons (SBAS) partnered to gain insight into whether inequities found in surgical society presidents may be present earlier. METHODS ACS, ASA, AWS, and SBAS presidents' CVs were assessed for demographics and scholastic achievements at the time of first faculty appointment. Regression analyses controlling for age were performed to determine relative differences across societies. RESULTS 66 of the 68 presidents' CVs were received and assessed (97% response rate). 50% of AWS future presidents were hired as Instructors rather than Assistant professors, compared to 29.4% of SBAS, 25% of ASA and 29.4% of ACS. The future ACS, ASA, and SBAS presidents had more total publications than the AWS presidents, but similar numbers of 1st and Sr. author publications. CONCLUSION Gender inequities in academic surgeon hiring practices and perceived scholastic success may be present at first hire.
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Affiliation(s)
- Elana Meer
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Byron D Hughes
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Colin A Martin
- Department of Surgery, University of Alabama Birmingham/Children's of Alabama, Birmingham, AL, USA
| | - Arturo J Rios-Diaz
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA; Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Viren Patel
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Carla M Pugh
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Cherisse Berry
- Department of Surgery, New York University School of Medicine, New York, NY, USA
| | - Steven C Stain
- Department of Surgery, Albany Medical Center, Albany, NY, USA
| | - L D Britt
- Department of Surgery, Eastern Virginia Medical School (EVMS), Norfolk, VA, USA
| | - Sharon L Stein
- Department of Surgery, University Hospitals/Cleveland Medical Center, USA
| | - Paris D Butler
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA.
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Woodward SG, Rios-Diaz AJ, Zheng R, McPartland C, Tholey R, Tatarian T, Palazzo F. Finding the Most Favorable Timing for Cholecystectomy after Percutaneous Cholecystostomy Tube Placement: An Analysis of Institutional and National Data. J Am Coll Surg 2021; 232:55-64. [DOI: 10.1016/j.jamcollsurg.2020.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/02/2020] [Accepted: 10/05/2020] [Indexed: 02/08/2023]
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17
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Abstract
Purpose. Powered by big data, predictive models provide individualized risk stratification to inform clinical decision-making and mitigate long-term morbidity. We describe how to transform a large institutional dataset into a real-time, interactive clinical decision support mobile user interface for risk prediction. Methods. A clinical decision point ideal for risk stratification and modification was identified. Demographics, medical comorbidities, and operative characteristics were abstracted from the electronic medical record (EMR) using ICD-9 codes. Surgery-specific predictive models were generated using regression modeling and corroborated with internal validation. A clinical support interface was designed in partnership with an app developer, followed by subsequent beta testing and clinical implementation of the final tool. Results. Individual, specialty-specific, and preoperatively actionable models incorporating clustered procedural codes were created. Using longitudinal inpatient, outpatient, and office-based data from a large multicenter health system, all patient and operative variables were weighted according to ß-coefficients. The individual risk model parameters were incorporated into specialty-specific modules and implemented into an accessible iOS/Android compatible mobile application. Conclusions. As proof of concept, we provide a framework for developing a clinical decision support mobile user interface, through the use of clinical and administrative longitudinal data. Point-of-care applications, particularly ones designed with implementation and actionability in mind, have the potential to aid clinicians in identifying and optimizing risk factors that impact the outcome of interest's occurrence, thereby enabling clinicians to take targeted risk-reduction actions. In addition, such applications may help facilitate counseling, informed consent, and shared decision-making, leading to improved patient-centered care.
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Affiliation(s)
- Jaclyn T Mauch
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Arturo J Rios-Diaz
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.,Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Geoffrey M Kozak
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.,Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
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18
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Gerard Woodward S, Rios-Diaz AJ, Zheng R, McPartland C, Winokur RS, Tholey R, Tatarian T, Palazzo F. Does Timing of Interval Cholecystectomy after Percutaneous Cholecystostomy Tube Affect Surgical Outcomes? Results from Nationwide and Institutional Analyses. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Rios-Diaz AJ, Cunning JR, Broach RB, Elfanagely O, Yenchih Hsu J, Zogg CK, Serletti JM, Kelz RR, Benjamin Morris J, Patrick Fischer J. Mesh: A Four-Letter Word When Performing Abdominal Surgery in Prior Hernia Repair Patients? J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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20
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Rios-Diaz AJ, Charbel Azoury S, Cunning JR, Broach RB, Patrick Fischer J, Lin IC, Levin SL, Chang BB. The True Story Behind Isolated Hand or Digit Traumatic Amputations: 1-Year Evaluation of Traumatic Amputation Treatment Course and Success of Replantation. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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21
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Rios-Diaz AJ, Zalewski A, Cunning JR, Metcalfe D, Palazzo F. Are We out of the Woods after Discharge? Nationwide Clostridium Difficile Infection Burden after Major Operation. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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22
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Akinbiyi T, Kozak GM, Davis HD, Barrette LX, Rios-Diaz AJ, Maxwell R, Tilahun ED, Jones JA, Broach RB, Butler PD. Contemporary treatment of keloids: A 10-year institutional experience with medical management, surgical excision, and radiation therapy. Am J Surg 2020; 221:689-696. [PMID: 32878694 DOI: 10.1016/j.amjsurg.2020.07.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/29/2020] [Accepted: 07/27/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION We evaluate a single center's, decade-long experience utilizing 3 approaches to keloid treatment: corticosteroid medical management (MM), surgical excision (SE), and surgical excision + radiation therapy (SE + RT). STUDY DESIGN Patients undergoing keloid treatment were identified (2008-2017). Outcomes were symptomatology/cosmesis for MM, and recurrence and complications for SE and SE + RT. Logistic regression was used to determine factors associated with recurrence and complications. RESULTS 284 keloids (95 MM, 94 SE, 95 S E + RT) corresponded to patients with a median age of 39.1 (IQR: 26.1-53), 68.1% Black, and followed-up for 15.4 months (IQR: 5.6-30.7). For MM, 84.6% and 72.5% reported improvement in cosmesis and symptoms, respectively. SE and SE + RT recurrence were 37.2 and 37.9%, respectively. In adjusted analyses, higher radiation doses were associated with decreased recurrence whereas male gender (OR 3.3) and postoperative steroids (OR 9.5) were associated with increased recurrence (p < 0.01). There were more complications in the SE + RT group. CONCLUSIONS MM resulted in at least some improvement. Recurrence rates after SE and SE + RT were similar. Female sex is protective, race does not affect outcomes.
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Affiliation(s)
- Takintope Akinbiyi
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Geoffrey M Kozak
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA; Department of Surgery, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Harrison D Davis
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Louis-Xavier Barrette
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Arturo J Rios-Diaz
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA; Department of Surgery, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Russell Maxwell
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Estifanos D Tilahun
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Joshua A Jones
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Robyn B Broach
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Paris D Butler
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA.
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Zheng R, Rios-Diaz AJ, Liem S, Devin CL, Evans NR, Rosato EL, Palazzo F, Berger AC. Is the placement of jejunostomy tubes in patients with esophageal cancer undergoing esophagectomy associated with increased inpatient healthcare utilization? An analysis of the National Readmissions Database. Am J Surg 2020; 221:141-148. [PMID: 32828519 DOI: 10.1016/j.amjsurg.2020.06.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/19/2020] [Accepted: 06/20/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Patients undergoing esophagectomy often receive jejunostomy tubes (j-tubes) for nutritional supplementation. We hypothesized that j-tubes are associated with increased post-esophagectomy readmissions. STUDY DESIGN We identified esophagectomies for malignancy with (EWJ) or without (EWOJ) j-tubes using the 2010-2015 Nationwide Readmissions Database. Outcomes include readmission, inpatient mortality, and complications. Outcomes were compared before and after propensity score matching (PSM). RESULTS Of 22,429 patients undergoing esophagectomy, 16,829 (75.0%) received j-tubes. Patients were similar in age and gender but EWJ were more likely to receive chemotherapy (24.2% vs. 15.1%, p < 0.01). EWJ was associated with decreased 180-day inpatient mortality (HR 0.72 [0.52-0.99]) but not with higher readmissions at 30- (15.2% vs. 14.0%, p = 0.16; HR 0.9 [0.77-1.05]) or 180 days (25.2% vs. 24.3%, p = 0.37; HR 0.94 [0.79-1.10]) or increased complications (p = 0.37). These results were confirmed in the PSM cohort. CONCLUSION J-tubes placed in the setting of esophagectomy do not increase inpatient readmissions or mortality.
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Affiliation(s)
- Richard Zheng
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA.
| | - Arturo J Rios-Diaz
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Spencer Liem
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Courtney L Devin
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Nathaniel R Evans
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Ernest L Rosato
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Francesco Palazzo
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Adam C Berger
- Department of Surgery, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
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Familusi O, Rios-Diaz AJ, Tilahun ED, Cunning JR, Broach RB, Brooks AD, Guerra CE, Butler PD. Post-mastectomy breast reconstruction: reducing the disparity through educational outreach to the underserved. Support Care Cancer 2020; 29:1055-1063. [DOI: 10.1007/s00520-020-05589-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/19/2020] [Indexed: 12/26/2022]
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25
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Rangel EL, Rios-Diaz AJ, Uyeda JW, Castillo-Angeles M, Cooper Z, Olufajo OA, Salim A, Sodickson AD. Sarcopenia as a tool for preoperative decision-making. J Trauma Acute Care Surg 2020; 86:377-379. [PMID: 30395013 DOI: 10.1097/ta.0000000000002115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Erika L Rangel
- Division of Trauma Burn and Surgical Critical Care Department of Surgery Brigham and Women's Hospital Harvard Medical School Boston, Massachusetts Center for Surgery and Public Health Department of Surgery Brigham and Women's Hospital Harvard Medical School Boston, Massachusetts Harvard T.H. Chan School of Public Health Boston, Massachusetts Division of Emergency Radiology Department of Radiology Brigham and Women's Hospital Harvard Medical School Boston, Massachusetts. Center for Surgery and Public Health Department of Surgery Brigham and Women's Hospital Harvard Medical School Boston, Massachusetts Harvard T.H. Chan School of Public Health Boston, Massachusetts Division of Trauma Burn and Surgical Critical Care Department of Surgery Brigham and Women's Hospital Harvard Medical School Boston, Massachusetts Center for Surgery and Public Health Department of Surgery Brigham and Women's Hospital Harvard Medical School Boston, Massachusetts Harvard T.H. Chan School of Public Health Boston, Massachusetts Division of Emergency Radiology Department of Radiology Brigham and Women's Hospital Harvard Medical School Boston, Massachusetts
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Tecce M, Cunning JR, Tecce M, Nathan SL, Rios-Diaz AJ, Whitely C, Broach RB, Serletti JM. Abstract 116. Plast Reconstr Surg Glob Open 2020. [PMCID: PMC7224739 DOI: 10.1097/01.gox.0000667520.55861.a5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Affiliation(s)
- Arturo J Rios-Diaz
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Zheng R, Rios-Diaz AJ, Thibault DP, Crispo JAG, Willis AW, Willis AI. A contemporary analysis of goiters undergoing surgery in the United States. Am J Surg 2020; 220:341-348. [PMID: 31948703 DOI: 10.1016/j.amjsurg.2020.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 12/26/2019] [Accepted: 01/05/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION We identified disparities and at-risk populations among patients with goiters undergoing thyroidectomy. MATERIALS AND METHODS The National Inpatient Sample (NIS) database was queried for patients with goiter who underwent thyroidectomy between 2009 and 2013. Multivariable logistic regression was used to determine factors associated with goiters undergoing thyroidectomy. RESULTS The study consisted of 103,678 patients with thyroidectomy and a goiter diagnosis, which included: simple goiter (n = 7,692, 7.42%), nodular goiter (n = 73,524, 70.92%), thyrotoxicosis (n = 14,043, 13.54%), thyroiditis (n = 1,248, 1.20%), and thyroid cancer (n = 7,169, 6.92%). Factors associated with operation for simple goiter included age >65 years (AOR 1.43 [1.15-1.79]), black race (AOR 1.35 [1.14-1.58]), and being uninsured (AOR 2.13 [1.52-2.98]). Patients with cancerous goiters undergoing thyroidectomy were less likely to be Black (AOR 0.38 [0.31-0.48]) or uninsured (AOR 0.25 [0.07-0.89]). DISCUSSION Understanding disparities within populations undergoing thyroidectomy for goiter may allow for targeted efforts to more effectively treat goiters nationwide.
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Affiliation(s)
- Richard Zheng
- Department of Surgery, Thomas Jefferson University Hospital. Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA.
| | - Arturo J Rios-Diaz
- Department of Surgery, Thomas Jefferson University Hospital. Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA.
| | - Dylan P Thibault
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - James A G Crispo
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Allison W Willis
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Alliric I Willis
- Department of Surgery, Thomas Jefferson University Hospital. Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA.
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Rios-Diaz AJ, Metcalfe D, Devin CL, Berger A, Palazzo F. Six-month readmissions after bariatric surgery: Results of a nationwide analysis. Surgery 2019; 166:926-933. [DOI: 10.1016/j.surg.2019.06.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/23/2019] [Accepted: 06/04/2019] [Indexed: 01/19/2023]
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Rios-Diaz AJ, Bevilacqua LA, Devin CL, Metcalfe D, Berger AC, Cowan SW, Palazzo F, Evans NR. Nationwide Management and Recurrence of Spontaneous Pneumothorax by Treatment Approach. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Zheng R, Rios-Diaz AJ, Liem S, Devin CL, Evans NR, Rosato EL, Palazzo F, Berger AC. Is the Use of Jejunostomy Tubes with Esophagectomy Associated with Increased Inpatient Health Care Utilization? J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Metcalfe D, Castillo-Angeles M, Rios-Diaz AJ, Havens JM, Haider A, Salim A. Is there a "weekend effect" in emergency general surgery? J Surg Res 2019; 222:219-224. [PMID: 29273370 DOI: 10.1016/j.jss.2017.10.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 09/25/2017] [Accepted: 10/12/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Weekend admission is associated with increased mortality across a range of patient populations and health-care systems. The aim of this study was to determine whether weekend admission is independently associated with serious adverse events (SAEs), in-hospital mortality, or failure to rescue (FTR) in emergency general surgery (EGS). METHODS An observational study was performed using the National Inpatient Sample in 2012-2013; the largest all-payer inpatient database in the United States, which represents a 20% stratified sample of hospital discharges. The inclusion criteria were all inpatients with a primary EGS diagnosis. Outcomes were SAE, in-hospital mortality, and FTR (in-hospital mortality in the population of patients that developed an SAE). Multivariable logistic regression were used to adjust for patient- (age, sex, race, payer status, and Charlson comorbidity index) and hospital-level (trauma designation and hospital bed size) characteristics. RESULTS There were 1,344,828 individual patient records (6.7 million weighted admissions). The overall rate of SAE was 15.1% (15.1% weekend, 14.9% weekday, P < 0.001), FTR 5.9% (6.2% weekend, 5.9% weekday, P = 0.010), and in-hospital mortality 1.4% (1.5% weekend, 1.3% weekday, P < 0.001). Within logistic regression models, weekend admission was an independent risk factor for development of SAE (adjusted odds ratio 1.08, 1.07-1.09), FTR (1.05, 1.01-1.10), and in-hospital mortality (1.14, 1.10-1.18). CONCLUSIONS This study found evidence that outcomes coded in an administrative data set are marginally worse for EGS patients admitted at weekends. This justifies further work using clinical data sets that can be used to better control for differences in case mix.
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Affiliation(s)
- David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom.
| | - Manuel Castillo-Angeles
- Center for Surgery and Public Health (CSPH), Brigham & Women's Hospital, One Brigham Circle, Boston, Massachusetts
| | - Arturo J Rios-Diaz
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Joaquim M Havens
- Center for Surgery and Public Health (CSPH), Brigham & Women's Hospital, One Brigham Circle, Boston, Massachusetts; Division of Trauma, Burn, and Surgical Critical Care, Brigham & Women's Hospital, Boston, Massachusetts
| | - Adil Haider
- Center for Surgery and Public Health (CSPH), Brigham & Women's Hospital, One Brigham Circle, Boston, Massachusetts; Division of Trauma, Burn, and Surgical Critical Care, Brigham & Women's Hospital, Boston, Massachusetts
| | - Ali Salim
- Center for Surgery and Public Health (CSPH), Brigham & Women's Hospital, One Brigham Circle, Boston, Massachusetts; Division of Trauma, Burn, and Surgical Critical Care, Brigham & Women's Hospital, Boston, Massachusetts
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Rios-Diaz AJ, Zheng R, Thibault DP, Crispo JAG, Willis AW, Willis AI. Understanding nationwide readmissions after thyroid surgery. Surgery 2018; 165:423-430. [PMID: 30545657 DOI: 10.1016/j.surg.2018.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 08/31/2018] [Accepted: 09/04/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND The 30-day readmission rate is increasingly utilized as a metric of quality that impacts reimbursement. To date, there are no nationally representative data on readmission rates after thyroid surgery. We aimed to determine national readmission rates after inpatient thyroidectomy operations and whether select clinical factors were associated with increased odds of postthyroidectomy readmission. METHODS Using the 2014 Nationwide Readmissions Database, we identified patients undergoing inpatient thyroid surgery as defined by the International Classification of Diseases, Ninth Revision, procedure codes for thyroid lobectomy, partial thyroidectomy, complete thyroidectomy, and substernal thyroidectomy. Descriptive statistics were used to report readmission rates, most common diagnosis and causes of readmission, and timing of presentation after discharge. Multivariable logistic regression models controlling for potential confounders were used to determine whether select factors were associated with 30-day readmission. RESULTS A total of 22,654 patients underwent inpatient thyroid surgery during the study period, 990 of whom (4.4%) were readmitted within 30 days. Among these, the most common diagnoses during readmission were disorders of mineral metabolism and hypocalcemia, accounting for 36.0% and 26.6% of readmissions, respectively. This held true regardless of the apparent indication for thyroid surgery (goiter, cancer, or thyroid function disorder) or timing of readmission after discharge. Calcium-related abnormalities were the top diagnoses at readmissions (22.1%). Most readmissions (54.6%) occurred within 7 days of discharge, with 24.6% within the first 2 days Factors associated with an increased odds of readmission included having Medicare (adjusted odds ratio [AOR] 1.47 and 95% confidence interval [CI] 1.03-2.11) or Medicaid insurance (AOR 1.44 [CI 1.04-1.99]), being discharged to inpatient post acute care (AOR 2.31 [CI 1.48-3.62]) or to home health care (AOR 1.78 [CI 1.21-2.63]), having an Elixhauser comorbidity score ≥ 4 (AOR 2.04 [CI 1.27-3.26]), and a duration of stay ≥2 days after the thyroid surgery (AOR 2.7 [CI 1.9-3.82]). The only complication during index admission associated with increased odds of readmission was hypocalcemia (AOR 1.5 [CI 1.1-2.06]. Indications for thyroid surgery were not associated with increased odds of readmission. CONCLUSION Readmissions after thyroid surgery are relatively low and occur early after surgery. The most common diagnoses identified on readmission were calcium and mineral metabolism disorders, which also were the most common cause of readmission. Socioeconomic factors, comorbidities, and complications during the index admissions were found to be associated with nonelective, postthyroidectomy readmissions. Recognition of these risk factors may guide the development of interventions and protocols to decrease readmissions.
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Affiliation(s)
- Arturo J Rios-Diaz
- Department of Surgery, Thyroid and Parathyroid Surgery Program, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Richard Zheng
- Department of Surgery, Thyroid and Parathyroid Surgery Program, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Dylan P Thibault
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - James A G Crispo
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Allison W Willis
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Alliric I Willis
- Department of Surgery, Thyroid and Parathyroid Surgery Program, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.
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Affiliation(s)
- Arturo J Rios-Diaz
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Jimmy Lam
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Cheryl K Zogg
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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Rios-Diaz AJ, Olufajo OA, Stinebring J, Endicott S, McKown BT, Metcalfe D, Zogg CK, Salim A. Hospital characteristics associated with increased conversion rates among organ donors in New England. Am J Surg 2017; 214:757-761. [PMID: 28390648 DOI: 10.1016/j.amjsurg.2017.03.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 03/01/2017] [Accepted: 03/27/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND It is unknown whether hospital characteristics affect institutional performance with regard to organ donation. We sought to determine which hospital- and patient-level characteristics are associated with high organ donor conversion rates after brain death (DBD). METHODS Data were extracted from the regional Organ Procurement Organization (2011-2014) and other sources. Hospitals were stratified into high-conversion hospitals (HCH; upper-tertile) and low-conversion hospitals (LCH; lower-tertile) according to conversion rates. Hospital- and patient-characteristics were compared between groups. RESULTS There were 564 potential DBD donors in 27 hospitals. Conversion rates differed between hospitals in different states (p < 0.001). HCH were more likely to be small (median bed size 194 vs. 337; p = 0.024), non-teaching hospitals (40% vs. 88%; p = 0.025), non-trauma center (30% vs. 77%; p = 0.040). Potential donors differed between HCH and LCH in race (p < 0.01) and mechanism of injury/disease process (p < 0.01). CONCLUSION There is significant variation between hospitals in terms of organ donor conversion rates. This suggests that there is a pool of potential donors in large specialized hospitals that are not successfully converted to DBD.
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Affiliation(s)
- Arturo J Rios-Diaz
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School & Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Olubode A Olufajo
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School & Harvard T.H. Chan School of Public Health, Boston, MA, USA; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School Brigham, Boston, MA, USA
| | | | | | | | - David Metcalfe
- Kadoorie Centre for Critical Care Research, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Cheryl K Zogg
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School & Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ali Salim
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School Brigham, Boston, MA, USA
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Meyer CP, Rios-Diaz AJ, Dalela D, Ravi P, Sood A, Hanske J, Chun FKH, Kibel AS, Lipsitz SR, Sun M, Trinh QD. The association of hypoalbuminemia with early perioperative outcomes - A comprehensive assessment across 16 major procedures. Am J Surg 2016; 214:871-883. [PMID: 29106849 DOI: 10.1016/j.amjsurg.2016.11.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 11/12/2016] [Accepted: 11/16/2016] [Indexed: 01/16/2023]
Abstract
BACKGROUND Poor nutritional status is thought to influence peri- and postoperative outcomes. We assessed the association of hypoalbuminemia, a surrogate for poor nutritional status, with perioperative outcomes in patients undergoing one of 16 major surgical procedures. METHODS Patients undergoing one of 16 major surgeries were identified using the ACS-NSQIP (2005-2011). Risk-adjusted logistic regression models examined the association of hypoalbuminemia on perioperative outcomes. RESULTS Overall, 204,819 complete cases were identified, of whom 25.4% underwent major cardiovascular, 19.0% orthopedic and 55.6% oncologic surgery. Patients with hypoalbuminemia had significantly higher rates of complications, reoperations, readmissions, prolonged length-of-stay and mortality (all p < 0.001). After adjustment, hypoalbuminemia was an independent predictor of overall complications in 12 of the procedures examined and 30-day mortality in 11 of the procedures. Individual perioperative complication profile varied widely among procedures. CONCLUSIONS Hypoalbuminemia exerts significant impact on perioperative outcomes. Its effect is procedure-specific and thus warrants targeted management strategies to improve surgical outcomes. In the absence of clear recommendations, our findings invite surgeons to assess preoperative albumin levels and to manage nutritional status accordingly.
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Affiliation(s)
- Christian P Meyer
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, One Brigham Circle, Boston, 02115, MA, USA; Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Arturo J Rios-Diaz
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, One Brigham Circle, Boston, 02115, MA, USA.
| | - Deepansh Dalela
- Center for Outcomes Research, Analytics and Evaluation, Vattikuti Urology Institute, Henry Ford Health System, 2799 West Grand Blvd, Detroit, 48202, MI, USA
| | - Praful Ravi
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, One Brigham Circle, Boston, 02115, MA, USA
| | - Akshay Sood
- Center for Outcomes Research, Analytics and Evaluation, Vattikuti Urology Institute, Henry Ford Health System, 2799 West Grand Blvd, Detroit, 48202, MI, USA
| | - Julian Hanske
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, One Brigham Circle, Boston, 02115, MA, USA
| | - Felix K H Chun
- Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Adam S Kibel
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, One Brigham Circle, Boston, 02115, MA, USA
| | - Stuart R Lipsitz
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, One Brigham Circle, Boston, 02115, MA, USA
| | - Maxine Sun
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, One Brigham Circle, Boston, 02115, MA, USA
| | - Quoc-Dien Trinh
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, One Brigham Circle, Boston, 02115, MA, USA
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Rios-Diaz AJ, Metcalfe D, Olufajo OA, Zogg CK, Yorkgitis B, Singh M, Haider AH, Salim A. Geographic Distribution of Trauma Burden, Mortality, and Services in the United States: Does Availability Correspond to Patient Need? J Am Coll Surg 2016; 223:764-773.e2. [PMID: 28193322 DOI: 10.1016/j.jamcollsurg.2016.08.569] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 08/30/2016] [Accepted: 08/31/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND The association between the need for trauma care and trauma services has not been characterized previously. We compared the distribution of trauma admissions with state-level availability of trauma centers (TCs), surgical critical care (SCC) providers, and SCC fellowships, and assessed the association between trauma care provision and state-level trauma mortality. STUDY DESIGN We obtained 2013 state-level data on trauma admissions, TCs, SCC providers, SCC fellowship positions, per-capita income, population size, and age-adjusted mortality rates. Normalized densities (per million population [PMP]) were calculated and generalized linear models were used to test associations between provision of trauma services (higher-level TCs, SCC providers, and SCC fellowship positions) and trauma burden, per-capita income, and age-adjusted mortality rates. RESULTS There were 1,345,024 trauma admissions (4,250 PMP), 2,496 SCC providers (7.89 PMP), and 1,987 TCs across the country, of which 521 were Level I or II (1.65 PMP). There was considerable variation between the top 5 and bottom 5 states in terms of Level I/Level II TCs and SCC surgeon availability (approximately 8.0/1.0), despite showing less variation in trauma admission density (1.5/1.0). Distribution of trauma admissions was positively associated with SCC provider density and age-adjusted trauma mortality (p ≤ 0.001), and inversely associated with per-capita income (p < 0.001). Age-adjusted mortality was inversely associated with the number of SCC providers PMP. For every additional SCC provider PMP, there was a decrease of 618 deaths per year. CONCLUSIONS There is an inequitable distribution of trauma services across the US. Increases in the density of SCC providers are associated with decreases in mortality. There was no association between density of trauma admissions and location of Level I/Level II TCs. In the wake of efforts to regionalize TCs, additional efforts are needed to address disparities in the provision of quality care to trauma patients.
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Affiliation(s)
- Arturo J Rios-Diaz
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Harvard TH Chan School of Public Health, Boston, MA; Department of Surgery, Thomas Jefferson University, Philadelphia, PA.
| | - David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Olubode A Olufajo
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Harvard TH Chan School of Public Health, Boston, MA
| | - Cheryl K Zogg
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Harvard TH Chan School of Public Health, Boston, MA
| | - Brian Yorkgitis
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Mansher Singh
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Adil H Haider
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Harvard TH Chan School of Public Health, Boston, MA
| | - Ali Salim
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Harvard TH Chan School of Public Health, Boston, MA
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Herrera-Escobar JP, Rios-Diaz AJ, Chowdhury R, Zogg CK, Wolf L, Olufajo OA, Schneider EB, Ordonez CA, Cooper Z, Haider AH. The ‘Mortality Ascent’: Risk of Death for Hemodynamically-Unstable Trauma Patients at Level II vs Level I Trauma Centers Rises at 4 Hours and Peaks at 7 Hours after Admission. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.08.157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Rios-Diaz AJ, Ortega G, Hsiung GE, Fahimuddin FZ, Pichardo MS, Lam J, Abdullah F, Qureshi FG. Influence of Surgical Technique on Outcomes for Uncomplicated and Complicated Appendicitis in Children: Evidence from NSQIP-Pediatric. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.08.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Rios-Diaz AJ, Lin E, Williams K, Jiang W, Patel V, Shimizu N, Metcalfe D, Olufajo OA, Cooper Z, Havens J, Salim A, Askari R. The obesity paradox in patients with severe soft tissue infections. Am J Surg 2016; 214:385-389. [PMID: 28818282 DOI: 10.1016/j.amjsurg.2016.05.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 04/25/2016] [Accepted: 05/01/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND The "obesity paradox" has been demonstrated in chronic diseases but not in acute surgery. We sought to determine whether obesity is associated with improved outcomes in patients with severe soft tissue infections (SSTIs). METHODS The 2006 to 2010 Nationwide Inpatient Sample was used to identify adult patients with SSTIs. Patients were categorized into nonobese and obese (nonmorbid [body mass index 30 to 39.9] and morbid [body mass index ≥ 40]). Logistic regression provided risk-adjusted association between obesity categories and inhospital mortality. RESULTS There were 2,868 records with SSTI weighted to represent 14,080 patients. Obese patients were less likely to die in hospital than nonobese patients (odds ratio [OR] = .42; 95% confidence interval [CI], .25 to .70; P = .001). Subanalysis revealed a similar trend, with lower odds of mortality in nonmorbid obesity (OR = .46; 95% CI, .23 to .91; P = .025) and morbid obesity (OR = .39; 95% CI, .19 to .80; P = .011) groups. CONCLUSIONS Obesity is independently associated with reduced inhospital mortality in patients with SSTI regardless of the obesity classification. This suggests that the obesity paradox exists in this acute surgical population.
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Affiliation(s)
- Arturo J Rios-Diaz
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Heath, Boston, MA, USA
| | - Elissa Lin
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Heath, Boston, MA, USA
| | - Katherine Williams
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Heath, Boston, MA, USA; Trauma, Burn and Surgical Critical Care Division, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Wei Jiang
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Heath, Boston, MA, USA
| | - Vihas Patel
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Heath, Boston, MA, USA
| | - Naomi Shimizu
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Heath, Boston, MA, USA
| | - David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Olubode A Olufajo
- Trauma, Burn and Surgical Critical Care Division, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Heath, Boston, MA, USA; Trauma, Burn and Surgical Critical Care Division, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Joaquim Havens
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Heath, Boston, MA, USA; Trauma, Burn and Surgical Critical Care Division, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ali Salim
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Heath, Boston, MA, USA; Trauma, Burn and Surgical Critical Care Division, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Reza Askari
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Heath, Boston, MA, USA; Trauma, Burn and Surgical Critical Care Division, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Rios-Diaz AJ, Lam J, Ramos MS, Moscoso AV, Vaughn P, Zogg CK, Caterson EJ. Global Patterns of QALY and DALY Use in Surgical Cost-Utility Analyses: A Systematic Review. PLoS One 2016; 11:e0148304. [PMID: 26862894 PMCID: PMC4749322 DOI: 10.1371/journal.pone.0148304] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 01/15/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Surgical interventions are being increasingly recognized as cost-effective global priorities, the utility of which are frequently measured using either quality-adjusted (QALY) or disability-adjusted (DALY) life years. The objectives of this study were to: (1) identify surgical cost-effectiveness studies that utilized a formulation of the QALY or DALY as a summary measure, (2) report on global patterns of QALY and DALY use in surgery and the income characteristics of the countries and/or regions involved, and (3) assess for possible associations between national/regional-income levels and the relative prominence of either measure. STUDY DESIGN PRISMA-guided systematic review of surgical cost-effectiveness studies indexed in PubMed or EMBASE prior to December 15, 2014, that used the DALY and/or QALY as a summary measure. National locations were used to classify publications based on the 2014 World Bank income stratification scheme into: low-, lower-middle-, upper-middle-, or high-income countries. Differences in QALY/DALY use were considered by income level as well as for differences in geographic location and year using descriptive statistics (two-sided Chi-squared tests, Fischer's exact tests in cell counts <5). RESULTS A total of 540 publications from 128 countries met inclusion criteria, representing 825 "national studies" (regional publications included data from multiple countries). Data for 69.0% (569/825) were reported using QALYs (2.1% low-, 1.2% lower-middle-, 4.4% upper-middle-, and 92.3% high-income countries), compared to 31.0% (256/825) reported using DALYs (46.9% low-, 31.6% lower-middle-, 16.8% upper-middle-, and 4.7% high-income countries) (p<0.001). Studies from the US and the UK dominated the total number of QALY studies (49.9%) and were themselves almost exclusively QALY-based. DALY use, in contrast, was the most common in Africa and Asia. While prominent published use of QALYs (1990s) in surgical cost-effectiveness studies began approximately 10 years earlier than DALYs (2000s), the use of both measures continues to increase. CONCLUSION As global prioritization of surgical interventions gains prominence, it will be important to consider the comparative implications of summary measure use. The results of this study demonstrate significant income- and geographic-based differences in the preferential utilization of the QALY and DALY for surgical cost-effectiveness studies. Such regional variation holds important implications for efforts to interpret and utilize global health policy research. PROSPERO registration number: CRD42015015991.
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Affiliation(s)
- Arturo J. Rios-Diaz
- Center for Surgery and Public Health, Harvard Medical School & Harvard School of Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Jimmy Lam
- Center for Surgery and Public Health, Harvard Medical School & Harvard School of Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Boston University, School of Medicine, Boston, Massachusetts, United States of America
| | - Margarita S. Ramos
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Andrea V. Moscoso
- Center for Surgery and Public Health, Harvard Medical School & Harvard School of Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Patrick Vaughn
- Center for Surgery and Public Health, Harvard Medical School & Harvard School of Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Harvard School of Dental Medicine, Boston, Massachusetts, United States of America
| | - Cheryl K. Zogg
- Center for Surgery and Public Health, Harvard Medical School & Harvard School of Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Edward J. Caterson
- Center for Surgery and Public Health, Harvard Medical School & Harvard School of Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
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Metcalfe D, Olufajo O, Rios-Diaz AJ, Haider A, Havens JM, Nitzschke S, Cooper Z, Salim A. Are appendectomy outcomes in level I trauma centers as good as we think? J Surg Res 2016; 202:239-45. [PMID: 27229096 DOI: 10.1016/j.jss.2016.01.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 01/07/2016] [Accepted: 01/12/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND Designated trauma centers improve outcomes for severely injured patients. However, major trauma workload can disrupt other care pathways and some patient groups may compete ineffectively for resources with higher priority trauma cases. This study tested the hypothesis that treatment at a higher-level trauma center is an independent predictor for worse outcome after appendectomy. METHODS An observational study was undertaken using an all-payer longitudinal data set (California State Inpatient Database 2007-2011). All patients with an ICD-90-CM diagnosis of "acute appendicitis" (International Classification of Diseases, Ninth Revision, Clinical Modification code 540) that subsequently underwent appendectomy were included. Patients transferred between hospitals were excluded to minimize selection bias. The outcome measures were days to the operating room, length of stay, unplanned 30-d readmission (to any hospital in California), and in-hospital mortality. Logistic and generalized linear regression models were used to adjust for patient- (age, sex, payer status, race, Charlson comorbidity index, weekend admission, and generalized peritonitis) and hospital-level (teaching status and bed size) factors. RESULTS There were 119,601 patients treated in 278 individual hospitals. Patients in level I trauma centers (L1TCs) reached the operating room later (predicted mean difference 0.25 d [95% confidence interval 0.14-0.36]), stayed in hospital longer (0.83 d [0.36-1.31]), and had higher adjusted odds of generalized peritonitis (odds ratio 1.63 [95% confidence interval 1.13-2.36]) than those in nontrauma centers. There were no differences in mortality or unplanned 30-d readmissions to hospital; or between level II trauma centers and nontrauma centers across any of the measured outcomes. CONCLUSIONS Odds of generalized peritonitis are higher and hospital length of stay is longer in L1TCs, although we found no evidence that patients come to serious harm in such institutions. Further work is necessary to determine whether pressure for resources in L1TCs can explain these findings.
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Affiliation(s)
- David Metcalfe
- Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts
| | - Olubode Olufajo
- Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | - Arturo J Rios-Diaz
- Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts
| | - Adil Haider
- Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | - Joaquim M Havens
- Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | - Stephanie Nitzschke
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | - Zara Cooper
- Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | - Ali Salim
- Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts.
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